‘.

"
Copyright1988by f " /Surgery,Incorporated

Current Concepts Review

CarpalInstability
BY JULIO TALEISNIK, M.D.*, IRVINE, CALIFORNIA

From the Department of Surgery (Orthopaedics) University of California at lrvine, lrvine

Before Rrntgen’s discovery of radiographs, only in- extrinsic ligaments, which course betweenthe carpal bones
juries of the wrist that resulted in gross distortion of osseous and the radius or the metacarpals, and intrinsic ligament~.
landmarks were recognized. The use of radiographs and whichoriginate and insert in the carpus 47"4s. Theseligament~
other diagnostic techniques has expanded the spectrum of were namedfor the bones from which they originate and
treatable injuries to include conditionsthat, until a fewyears into which they insert. The palmar radiocapitate, palmar
ago, were unknownor extremely rare. It is nowuniversally rMioluna_te, palmar radioscapholunate, dorsal radiocarpal,
agreed that there is a spectrumof carpal injuries that ranges and dorsal inte’r~-arpal ligaments, as well as the ligamentous
from sprains to major fractures, dislocations, and fracture- complexin the ulnocarpal space47, are particularly impor-
dislocations. Within this spectrum, carpal instabilities, tant. Biomechanically,the extrinsic ligaments are stiffer,
whichwerefirst mentionedby Gilford et al. ~6 and later were while the intrinsic ligaments are capable of greater elon-
’a,
described in association with scaphoid fractures by Fisk 3°.
gation before permanentdeformation occurs
have assumed increasing importance. The presence of a collateral ligament system of the
In 1972Linscheidet al. ~-8, ~-’,
and in 1975Dobyns et al. wrist, of the traditional construct, has been questioned. In
wrote landmarkarticles on carpal instability. Theydefined 1979, Kauer stated that the unique range of motion of the
traumatic instability, described radiographic findings, pro- wrist "excludes collateral ligaments as componentsof the
vided a working classification, suggested a mechanismof ligamentous apparatus of the wrist ’’2~. The function of a
injury, and proposed the first approach to treatment. Most true collateral structure, as is seen in hinge (ginglymoid)
subsequent reports on this subject have only refined or ex- joi.n.ts, is not possible in a joint like the wrist, whichhas
pandedon the conclusions of these authors. the anatomical appearanceof a condylar or trochlear artic-
5~’s5.
ulation but the actual functionof a multiaxialenarthrosis
Anatomy Collateral ligaments wouldbe useful only if radiocarpal
~ The proximalsurface of the carpus is an oblongcondyle motion were limited to flexion and extension. Wh~-6ulnar
that articulates with the compositesurface of the radius and and radial deviation are added, a static collateral ligament
the triangular fibrocartilage. The structure is not a fixed, would, in effect, restrain lateral and medialangulatory dis-
immutablecondyle, but rather is a structure of variable placements.
geometry-that changes shape to accommodateto the re- Kauer proposed that the wrist has an "adjustable col-
quirements for space, during motion, between the forearm lateral system"of musclesacting as true collateral support:
and the hand22. These changes are possible because the the extensor carpi ulnaris for the ulnar side of the wrist and
carpal condyle, which consists of eight bones that are ar- the extensor pollicis brevis and abductor pollicis longus for
ranged in two rows, creates a multifaceted articulation to the radial side. Freque_.p_ntly,the volar part of the capsuleof
meet the need for mobility and stability of the wrist. the wrist has an area of weakness,called the space of Poiriml,
The slopes of the articulating surface of the radius and bdtweenthe main ligamentous structures that are attached
the shapes of the carpus define vectors that fall in prede- prdk~mallyon the lunate and distally on the capitate.
termineddirections whenthe wrist is loaded5g. In particular,
the articular surface of the distal part of the ~es Kinematics
~n.~a palmar and u-gl’ff~ direcnon, creanng a palmar-ulnar In general, .no tendonsar~ directly attached tO the car-
ve_ctor under load. However,tlae articular surface xs sup- pus. Thereare thre_~2_~stems of tendonsthat cross the wrist:
ported by a ligamentous systemthat prevents unidirectional the’ extrinsics of the fingers, whichcross the center of2he
rmgr~n of the c__~..~_~_ ~,rist anal exert minimumabduction-adduction momenton
Th-g~are two major groups of ligaments of the wrist: the joint (the center of rotation of the wrist lies within the
head of the cap{ta-~ the flexors and extensors of the wrist,
* Orthopaedic Surgery Medical Group, 1201 West La Veta, Suite which surroun~"-the periphery of the joint and allow posi-
501, Orange, California 92668. tioning of the wrist without motionof the fingers; and the
 CARPAL INSTABILITY 1263

tendons passing around the radial styloid process, which intercalated system is controlled through both ligamentous
can exert markedradial deviation29. Withinthis system, the and contact-surface constraints. The contact surface pro-
proximal carpal row behaves as an intercalated segment in vides stability throughout motion, while at the same time
26. transmitting loads 6~. This is a kinetic, rather than simply a
a three-joint link system As such, the systemwouldtend
to collapse under compressiveload were it not for the pres- kinematic, concept, incorporating transmissions of longi-
ence of the scaphoid across the mid-carpal joint 32. Ananal- tudinal load into the abstract analysis of carpal motionwith-
out load. Weber 6~ thought, as did Navarro39 before him, that
ogy has been made between this mechanismand a slider-
crank control, in which a three-bar linkage (represented by it is useful to think of the wrist in terms of longitudinal
the radius, lunate, and capitometacarpallinks) is stabilized columns when attempting to understand control of inter-
’’28.
by the scaphoid "crank calated segments through joint contact. He believed that
Navarro proposed an entirely different concept that there is; a force-bearing column,composed of the distal part
of the vertical or columnar carpus 38"39"47. He proposedthat of the radius, the lunate, the proximal two-thirds of the
scaphoid, the capitate, the trapezoid, and the articulation.of
there are..three longitudinal car~ columns:a lateral column
(the scaphoid), a medial column (the triquetrum), and the carpus with the second and third metacarpals. The func-
cen-traTffl-~xion-extensioncolumn(the lunate and the entire tion of the force-bearing columnis to transmit forces that
distal carpal row). Within this system, the lateral column are generated bv the hand to the forearm.
61, a second control column con-
According to Weber
(the scaphoid) functions as a stabilizing rod across the lun-
atocapitate joint. It is also responsible for palmarflexion of sists of the distal part of the ulna, the ulnocarpal complex,
the proximal carpal row during radial deviation, as the the triquetrum, the hamate, and the bases of the fourth and
scaphoid palmar flexes to accommodateto the__ shrinking fifth metacarpals. The transmission of longitudinal force by
space betweenthe trapezium and the radial styloid process. this ulnar columnis limited because the triangular fibro-
Wh~lunate joint is dissociated, the absence of cartilage has greater compliancewith applied loads. Instead,
this function allows palmarflexion of the scaphoidto coexist compressive forces on the ulnar column are deflected
with dorsiflexion of the lunate and triquetmm in the same throughthe rigid, planar hamate-capitatearticulation of the
proximal carpal row. central force-bearing column.In addition, the configuration
Similarly, during., ulnar deviation, shortening of the of the hamate-triquetrumjoint is well suited to provide ro-
distance between the hamate and the styloid proces.s~ fa- tational control.
c~e triquetrum migrates distally on the ha- The third columnis the thumb-axis column6~, which
~
mate and dorsiflexes simultaneously .... . BecauseoT-t-~e includes the distal third of the scaphoid, the trapeziotra-
rr~-rh-ff~position of th6 triqu-~ral facet of the hamate, pezoid joint, and the base of the first metacarpal. This col-
this distal progression of the triquetrum forces the hamate umnacts a support for the base of the thumb, allowing
in a palmar direction. The axis of the lunate also becomes independent function of that digit. Compressiveloads on
palmar in relation to the capitate. Compressiveforces from this columnare also deflected to the central force-bearing
the capitate on the lunate then assist in rotating the lunate column,along the intact scaphoid, and across the trapezium,
into dorsiflexion6~. Whenthere is a lunatotriquetral disso- trapezoid, and scaphoid to the capitateo _
ciation, this action can no longer be transmittedto the lunate. Unlike the carpal-ring and variable-geometry concepts,
This explains howa dorsiflexed triquetrum can coexist with the columnartheories account for the presence of forces and
a patmar flexed lunate-scaphoid unit within the same prox- loads that are, by necessity, transmitted from the hand to
imal carpal rows4. These scaphoidinduced and triquetrum- the forearm in a longitudinal direction. ~~-
induced rotations allow the proximalcarpal row to function CarpalInstability
as an intercalated segment. Thus the carpus has variable
geometry, maintaining the useful space or distance between Dobyns et al. 12 definedtraumaticinstability of the wrist
the radius and the distal carpal row-’. Recently published as "a carpal injury in which loss of normal alignment of
experimental data supported this concept and denied the the c~~e~rly or la~iE"’TThey recogmzed
44.
validity of the columnartheory of carpal function fou~rn~3 ypes o carpal instability: dorsiflexion~ palmar
In 1981 Lichtmanet al. 27, and in 1984 Alexander and flexion, ulnar translocation, and dorsal subluxation. Dor-
~,
Lichtman observed that a columnarconcept fails to ac- siflexiion instability, which is the most frequent, is present
,count for transverse, or perilunate, instability, as well as whenthe lunate has rotated into dorsiflexion, as seen on
for clinical patterns of transverse mid-carpal and proximal lateral radiographs.Thecapitate displaces dorsal to the long
carpal instabilities. Theyproposedthe oval-ring theory, ac- axis of the radius, producing a zigzag radiolunatocapitate
cording to whichthe carpus is a transverse ring, formedby aligninent that is called dorsal intercalated-segmentinsta-
the distal and proximal carpal rows and joined by two phys- bility (DISI). The intercalated segment is the lunate, s
iological links one radial (the mobile scaphotrapezial identified on lateral radiographs. Theopposite pattern, volar
joint) and the other ulnar (the rotatory triquetrohamatejoint). intercalated-segmentinstability (VISI), is characterized
Weber’sinvestigations have contributed to the under- palmar flexion of the lunate. In the third type of carpal
standing of the biomechanicsof the wrist and have clarified instability, ulnar translocation, the carpus shifts ulnarward.
6°.
the role of the triquetrum He emphasizedthat the carpal The fourth type, dorsal subluxation, is commonly seen after
 1264 JULIO TALEISNIK

a malunited fracture of the radius associated with reversal dividuals is important in determining the outcomesof oth-
of the normalpalmartilt of the articular surface. Although erwise identical injuries to the wrist 47. A fall on the
Dobynset al.I-" consideredan opposite, volar type of carpal outstretched upper extremity whenthe wrist is in dorsiflex-
subluxationto be theoretically possible, it wasnot until after ion mayresult in a fracture in somepatients and a dislocation
3.
their study was publishedthat isolated cases werereported in others. Hypermobilityof the joint is frequent in patients
The.~e_caq~a! ahn~.malitie_s..,..whichcan be clearly re_ c- in whoman injury elongates or partially or completelytears
ognizedon routine radiographsby t__he loss of normalalign: a ligament. In addition to the variation in behavior of lig-
mento-~th~g~fp--aq-b-o~es,havebeencalled static 49s°. There aments amongdifferent people, it has been suggested that
is a se~-~-~ff’~~p~t’-d-a-~alinstability for whichthe routine there is a qualitative difference in yield strength of different
radiographic findings are within normal limits. With this ligaments in the sameindividuaP6. Accordingto this thesis,
type of instability, the patient can voluntarily ch~he the weakestligaments are in the radial and palmarquadrants
carpal alignment from normal to abnormaland the reverse. of the wrist 36. This mayexplain the presence of clinical
Sornetimes-thi-e instability can be’~producedby manipula- instability without radiographic, arthrographic, or surgical
tion only; again, all other ancillary tests, with the possible evidenceof a torn ligament. As is true for carpal dislocations
exception of bone scans, are normal. This formof instability and fracture-dislocations, the point of application, magni-
is called dynamic, and it mayoccur between the scaphoid tude, and direction of the force of injury, and the position
and the lunate, betweenthe lunate and the triquetrum, or of the hand at the time of impact, are important in deter-
betweenthe carpal rows at the mid-carpal joint. miningthe resulting carpal instability.
The most commoncarpal instability is secondary to Most frequently, injuries follow compressiveloading
ligamentousdisruption betweenthe scaphoid and the lunate, of the wrist in s0~e ~ ’ ’ ~-on. Rotgtion ~t"
the’ second most common instability is that between’ t-he either the forearm or the wrist itself is frequently present.
lunate and the triquetrum, and the third most commonis In a study of carpal dislocations and fracture-dislocations,
dynamicmid-carpal instability. Ulnar translocation rarely Mayfieldet al. 35 loaded the wrists of cadavera in extension,
results from injury, but it is frequent in wrists that are ulnar deviation, and intercarpal supination. The resulting
affected by rheumatoidarthritis. Carpal instability second- sequence of injury, whichthey caiidd progressive perilunar
ary to malunionof a fracture of the distal part of the radius instability, included four stages. At the end of st~ge_L..a
is also common. scapholunate diastasis, the mostfrequenttyp~..of carpa_lin.___:
Anatomically,there are three types of instability: lat- st’a-b-ility, wasproduced.Progressionof the loadingled t____o
eral instability, whichusually occurs betweenthe scaphoid s ~.~sal dislocation of the capitate. In sta.~e II!_,_1lae ~
and the lunate; medial instability, whichoccurs betweenthe triquetrurn gradually dislocated from the lunate, resulting
triquetrum and the lunate or betweenthe triquetrum and the ~n tnquetrolunate diastasis or an avulsion fracture__oLL~he
hamate(mid-carpal instability); and proximal instability, !~. Stage IV was typified by dislocation of the lun-
which occurs when the abnormal carpal alignment is sec- ate, the greae~e~e~e~e~e~e~e~e~st degreeof perilunateins/~b~li~y.
’ .....
ondaryto an injury of the radius or to a massiveradiocarpal .... Clinical evidence has suggested that-I~ading on the
disruption (dorsal carpal subluxation, mid-carpalinstability ulnar side of the carpus, with the carpus hyperpronated,
se.condary to malunionof the distal part of the radius, and results in triquetrolunate ~njury ~. In addition, i~-younger
49"~1’
ulnar 53.
translocation) patients whohave ligamentous laxity, a malunited fracture
Th~patterns of instability that result fromligamentous of the distal part of the radius that results in loss of normal
disruption ~n the proximal ca.rpal row -- that ~s, between palmartilt of its distal articular surface mayallow immediate
the._~.aph0id a--~’~ ~o~i’b~t~he or progressive carpal subluxation. This subluxation may
triquetrum-- include.._s_capl~olunate.-dissociation.~ahizh_~e-occurat the level of either the radiocarpaljoint (dorsal carpal
sults in dorsal intercalated-segment instability, and luna- subluxation) or the mid-carpal joint (mid-carpal instability
t o t ri~dral_.di~cj.ati.oxt~2~hich-lead~to-vot-ar-intereat~t e d - secondary to a malunited fracture of the distal part of the
S.e.~ment s o c iaOve 53.
in st ability.T_~__~e_s_~’Jajxtries-ar_e-g.~s_.o_f.~s radius)
1.
carp_~instability.!
Non-dissociativecarpal instability also results in dorsal Diagnosis
and volar intercalated-segmentinstability, but it is not as- The diagnostic process starts with documentation., of
¯ "~ sociated with a ligamentous injury in the proximal carpal the mechanismof injury and of the patient’s complaints. ....
¯ row; allb three major bones continue to f~i For patients whohave dynamicinstability, so-called trick
~ Non-dfss’gb’N~tive carpal instabilities include ~torsal ~arpal motions or snaps must be observed. Anylocalized tender-
subluxation, mid-carpal instability in whichrotation of the ness should be elicited. The clinical findings must be kept
bones in the proximal carpal row leads to dorsal or volar in mind, because frequently these patients have normalfind,;
intercalated-segment instability, volar carphl subluxation ings on routine radiographs. Only after the routine radio-
(which is very infrequent), and someulnar translocations. ,graphs have been seen to be normalcan dynamicinstability
and tenderness be investigated further. To assess dynarnic
Mechanism of Injury instability, radiographs are madeboth before and after a
, Assessment of the laxity of ~erent in- position of instability has been assumed s’- or the carpus has
 CARPAL INSTABILITY
been manipulated. To assess tenderness, radiographs are
madewith metal markers at the site of the tenderness.
Additional documentationcan be obtained by injecting
a small amountof an anesthetic agent into the tender joint
and recording changes in the pattern of pain, mobility, and
grip strength. Manipulationof the scaphoid by the examiner
mayreproducethe patient’s sensation of instability or even
cause subluxation of the proximal pole of the scaphoid (the
Watsontest) 52. If the ulnar side of the carpus is involved,
triquetrolunate ballottement42 3~or mid-carpal manipulation
is performed.
The initial radiographic examinationis tailored to the
patient’s complaints and clinical findings. On a postero-
anterior radiograph, three major features are evaluated
sequentially~7: (1) the carpal arcs, which are usually con-
centric and which are traced along the proximal and distal
surfaces of the proximalcarpal row and the proximalsurface
of the distal carpal row; (2) the symmetry
of the joint spaces;
and (3) the shapes of the individual bones. Lateral radio-
graphs are useful for the evaluation of radiolunatocapitate
alignment and for the determination of angles betweenthese
bones and the scaphoid.
Radiographic Findings
Scapholunate Dissociation
For a wrist that has scapholunatedissociation, antero-
posterior radiographs showa scapholunate gap that is wider
than the scapholunatespace in the opposite, uninjured wrist.
This gap is usually more noticeable on an anteroposterior
radiograph that is madewith the wrist supinated than it is
on the more usual posteroanterior radiograph (made with
the wrist pronated). It is important to direct the x-ray beam
parallel to the scapholunatejoint. Moneim 37 and Frot et al. ~5
described radiographic projections to accomplish this ob-
jective.
.The cortical ring sign is produced.by the cortex of the
distal ~ie 0fihe palmai’~exedscaphoid ~s seen 2’gaz.end-on
The scaphoid is foreshortened. The distance between the
s~~ng., and t_he proximal pole of the scaphoid is de-
creased to less than seven millim~~
l~rmal scapholunatotriquetral correlation -- a fore-
shortened (palmar flexed) scaphoid coexists with a quad-
rilateral (dorsiflexed) lunate, and the triquetrumis in a distal
position (dorsiflexed) in relation to the hamate.
Negative ulnar variance has been found to be signifi-
cantly more frequent in patients whohave a post-traumatic
scapholunatedissociation~.4°. At present, the biomechanical
implications of this finding are conjectural.
Posteroanterior radiographs that are made with the
wrist in ulnar, deviation, in radial deviation, and with the
application of longitudinal compressiveload~2 (with the fist
clenched) may also show a widened scapholunate gap in
the wrist that has scapholunatedissociation.
Lateral radiographs are valuable to assess the opposite
rotations of the lunate and the scaphoid. Whenthe scapho-
lunate joint is dissociated, the scaphoid is palmarflexed,
with its long axis perpendicular to that of the radius, and
VOL.70-A, NO. 8. SEPTEMBER
~988
1265
the lunate is dorsiflexed (dorsal intercalated-segmentinsta-
bility). The scapholunate angle, which normallyranges from
30 to 60 degrees and averages 46 degrees, increases to more
’2’28
than .70 degrees
Triquetrolunate Dissoci_i~on
Aposteroanterior radiographof a wrist that has a fully
developedvolar intercalated-segment instability showsthe
scaphoid to be volar flexed and foreshortened. The ring sign
is present, and the distance betweenthe ring and the prox-
imal pole of the scaphoid is decreased. However,unlike the
ca,:e with scapholunate dlssocmt~ons, tl~e lunate is volar
fle’:~angular. The triquetrum is dorsiflexed and dis-
taT’in relation to the hamate.Thedistance betweenthe. ulnar
head and the triquetrum is shortened (the Mayersbach
sign) -. The convexoutline of the proximal carpal condyle,
called the Shentonline of the wrist by Linscheid, is inter-
rupted by a step-off betweenthe lunate and the triquetrum.
Lateral radiographs show the lunate to be palmar
flexed. If the triquetrum and the lunate can be identified,
the normal triquetrolunate angle of approximately- 16 de-
~9.
grees is convertedto a neutral or positive angle
Ulnar Translocation
Abnormal translation of the lunate in an ulnar direction
is pathognomonic of ulnar translocation. McMurtryet 33 al.
described a reproducible method of measuring what they
called the carpal-ulnar distance -- that is, the distance be-
tweenthe center o_f_rotation of the carl3U-~-~-iiitIi~h6gdof
..me cap~tate,
¯ -o .-7-~---7,.
ana anne .. ----
extendm~ the.--5 -
lo~tudinal axis of
the u.lna di_i~_tal~.. In normalwrists, dividingthis distanceby
the length of the third metacarpalconsistently results in a
ratio’of 0.30 __+0.03. In wrists that haveulnar translocation,
the ratio is smaller, indicatingthat the capitate andthe lunate
are translocated in an ulnar direction.
A similar method, using the lateral part of the-radial
cortex instead of the longitudinal axis of the ulna, has been
proposed6. Accordingto the position of the scaphoid, two
type.s of ulnar translocation can be seen~2. In TypeI, the
entire cart~_u__fis., including the scaph0jd , is displ~
distance betweenthe radial styloid process and the scaphoid
is widened tz. In Type II, the rel~between tn~-
o.jd_.=andthe radius, andhll t 5_th~.disla~e,_b
" ....
otu,~~.,n..... e-scaph-
o.id and the radial sty~ess, remains normal, but the
sc~olunate space is widene~l.’7--
The distinction betweenthe two types of tilnar trans-
location is important, because the appearance of a wide
scapholunate gap maylead to the erroneous diagnosis of ,..
scapholunate dissociation. If this happens, any attempt at : ....
stab!ilizing whatappears to be a rotatory subluxation of the "
scaphoid will fail to correct the underlying problem,which
is ulnar migration of the carpus~. Ulnar translocation fre- ’ ,!
quently is accompaniedby volar flexion instability of.the: ’~
proximalpart of the carpus.
DynamicInstability
Dynamicforms of dorsal or volar intercalated-segment
 JULIO TALEISNIK
instability are secondary to loss of support across the ulnar graphic control maycorrect a fresh scapholunate dissocia-
half of the mid-carpal joint z7. Routine radiographs usually
are considered normal, although the alignment of the ra- tion 7. In most patients, however,surgical visualization and
diocarpal link mayhave a palmaror dorsiflexion bias. Many repair of the torn ligaments, using dorsal and palmar inci-
patients whohave dynamicinstability can actively subluxate sions, is morereliable.
the wrist with the forearm pronated and the wrist in or out For a chronic scapholunatedissociation that is not as-
of ulnar deviation27. sociated with osteoarthritis, the techniqueof reconstruction
Diagnostic radiographs are made with the patiem’s of the ligaments by threading tendonsthrough drill-holes in
forearm and hand pronated, elevated on a bolster, and placed either the carpal bones or the radius, or both, has proved
against the radiographic plate, whichis held vertically. The to be unreliable and is very demandingtechnically~8,20.~.
x-ray beam is directed horizontally across the wrist. The Instead, reattachment of the scapholunate ligament, which
patient is then asked to reproduce the position of abnormal is usually torn from the scaphoid, can be attempted. The
carpal alignment. (If the end-point of active motion that reattachment can be augmentedby attaching tendinous or
produces the subluxation is different from that just de;- capsular tissue along the scapholunate space~9. A dorsal
scribed, the radiographs should be madewith the wrist in capsuloligamentodesis, as described by Blatt 4.~, also can
that position.) Lateral radiographswill showa volar or dor- be used instead of, or in addition to, the repair of the
sal intercalated-segmentinstability, with loss of the align- ligament. For a capsuloligamentodesis, a dorsal capsular
mentbetweenthe capitate and the radius that is normal for flap, whichis left attached to the radius proximally, is in-
that patient52. In mostpatients, this approacheliminates the; serted in the distal part of the scaphoidto tether the distal
need for cineradiographic studies. pole dorsally, keeping the scaphoid from subluxating in a
palmardirection.
Special Studies and Ancillary Procedures
Y~ced systemic la_xity_.~_of
Bone scintigraphy and arthrography ~~ which, when the~-j°!nt~’--g°werfi’ ~ ~.and
deemednecessary, probably are best done in that order- manding occupationbenefit fromstabilization a-a__p~y~de_
o-f._the_s.c_aph-
are useful in the diagnosisof carpal instability. In patients oid-lyya limited a~--fflSg6-desisbetweerkXh_he_s_c_aphoid,__th
whohave carpal instability, the uptake of isotope is in- trapezium, and the trapezoid, as ~y Watson and
creased, probably secondary to hyperemia accompanying ~pton~. This pr~-~dure, as well as all other~rn--~ed
reactive synovitis. Whena scan is negative, it suggestseither carlS~rodeses, must preserve the size and outer shape
that there is no injury or, morefrequently, that the problem of the fused unit and must not interfere with the relationship
is minor and can he treated non-operatively. Becauseit is and alignment of the surrounding carpal joints. The long-
not specific, a positi’ve scan should not be used alone in term results of the procedurehave thus far dispelled doubts
determining the diagnosis, but should be employedin con- regarding the wear and tear of joints neighboring the site
junction with other tests. Triphase scans are preferable46; --of a partial carpal arthrodesis-’4.z~.However, the results have
whena posteroanterior imageis positive, lateral and oblique not been uniformlypredictable~. Not only is there residual
images should be madeas well~°. This helps to localize the limitation of motion, but in somepatients the procedurehas
carpal problem. also been followed by weakness and pain during forced
loading of the wrist in dorsiflexion.
It is Arthrography
important thatis the
helpful
flow in
of finding ligamentous tears.
opaquematerial be followed Untreated chronic scapholunate dissociation commonly
in an image intensifier to .find leaks and abnormalcom-
,results i.n a.~ern-ofosteoarthritis-.and.subluxati~n
advancedcolla se ....... that has
munications45. Digital fluoroscopy has been used advanta- oeen caltea-s~co_pholunate
geously for the same purpose. Arthrograms that are made ically, degenerative changes occur in areas of abnormal
by injecting all three major joints (radiocarpal, mid-carpal, loading, initially betweenthe radial styloid process and the
and distal radio-ulnar) with contrast medifimare helpful and scaphoid and later in the unstable lunatocapitate joint, as
sometimesobligatory6~. It is important to keep in mindthat the capitate .sublu_x__ale_s_do~al_!l.g on the lunate Thereco
communicationsbetween tfiga~tterent compartmentso-’~he mended treat~--een, ¢ .... ¯ -,~’~
wns~e not necessarily tl~e ~~~-’~n- ~r tins roNem consists of "re ~ lacement
rec°m-2.
unstable
.!~... m~d
~t,s.,o.r ~~t t_hrou~~fus_io
re.placerr_~ n .....
~taomzatmn
e of_~th
Arth~roscopyis valuabie for direct ~’isu~lization of the in-
l,unatotriquetral ~
Instability - i ~?.~ f(
tercarpaljoints~a.62.
Computedtomography is probably not usefui in the The acutely symptomaticlunatotriquetral joint maybe ~
diagnosis of carpal instability. Magneticresonance imaging ts’eated successfully by local injection of steroids and im,
is promising, although its value and applications for the mobilization aboveto the elbow. If this approach fails o~
wrist have yet to be determined. if the instability is ch~-onicand disabling, the lunatotriquetral ~
ligament can be repaired directly, with or without capsular
Treatment or’ ligamentousaugmentation4~.Wherethere is an ulnar-plus
Scapholunate Dissociation variant, especially if the triangular fibrocartilage is perfo-
Manipulation and closed pinning under cineradio- ral:ed, ulnar shortening is the procedure of choice. Luna-
totriquetral arthrodesis maybe used whenthe other tech-
 CARPAL INSTABILITY 1267

34. Dynamic Volar and Dorsal

¯~ niques are not feasible
Intercalated-SegmentInstability
Ulnar Translocation A trial of non-operative management,including above-
Surgical exploration of an acute ulnar translocation the-elbow immobilization with the elbow supinated, local
as- i routinely discloses a massive dorsal and palmar tear of the injections of steroids, and administration of anti-inflam-
:ion t
capsule from the radius. Frequently, a previously unsus- matorymedication,is justified if the patient had not received
sin ~
red pected tear of the scapholunate ligament is present. Repair such treatment previously, particularly if he or she has an
).41 of the ligament, evenwhenthe injury is acute, is unreliable, occupation that is not physically demanding.However,for
Experiencewith the treatment of ulnar translocation in ar- patients whoare disabled by persistent or recurrent symp-
ich
thritic wrists 6’49 has suggestedthat relocation of the carpus toms, stabilization of the mid-carpal joint through limited
Fhe
and maintenance of reduction by radiolunate arthrodesis arthrodesis, capsuloligamentodesis, or tenodesis is jus-
or
maybe a more reliable and satisfactory technique, zL52.
tiffed
’sal
;all
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